“Young people most at risk of HIV” (IATT/YP) 2010

Young People Most at Risk of HIV
A Meeting Report and Discussion
Paper from the Interagency
Youth Working Group, U.S. Agency
for International Development,
the Joint United Nations
Programme on HIV/AIDS (UNAIDS)
Inter-Agency Task Team on
HIV and Young People, and FHI

Young People Most at Risk of HIV: A Meeting Report and Discussion Paper from the Interagency Youth
Working Group, U.S. Agency for International Development, the Joint United Nations Programme on
HIV/AIDS (UNAIDS) Inter-Agency Task Team on HIV and Young People, and FHI. Research Triangle Park,
NC: FHI, 2010.

Contributors are listed below according to the chapters of the report:
Framing the Issue: Bruce Dick, World Health Organization (WHO); Ward Rinehart, consultant;
and Diane Widdus, UNICEF.*
Young Men Who Have Sex with Men: Kent Klindera, amfAR; Rafael Mazin, Pan American Health
Organization (PAHO); Brian Ackerman, Advocates for Youth; Donna Sherard and Brian Pederson,
Population Services International (PSI); Philippe Girault and Bill Finger, FHI; Cheikh Traore,
United Nations Development Programme, and Bruce Dick, WHO.
Young People Who Sell Sex: Jay Silverman, Harvard School of Public Health; Brad Kerner,
Save the Children; Jenny Butler, UNFPA; Bruce Dick, WHO; Kwaku Yeboah* and Bill Finger, FHI.
Young People Who Inject Drugs: Diane Widdus, UNICEF;* Shimon Prohow, PSI;* Kyla Zanardi and
Caitlin Padgett, Youth RISE;* Mary Dallao and Simon Baldwin, FHI; Ward Rinehart, consultant;
and Bruce Dick, WHO.
Conclusions: Shanti Conly and Debbie Kaliel, USAID; Bruce Dick, WHO; Ward Rinehart, consultant.
Overall report: Bruce Dick and Jane Ferguson, WHO; Jenny Butler and Mary Otieno, UNFPA; Debbie
Kaliel and Jenny Truong, USAID; Ward Rinehart, consultant; Joy Cunningham and Karah Fazekas, FHI.
Peer review: Jyothi Raja N.K. and Michael Bartos, UNAIDS Secretariat.

This report draws heavily on materials presented at a meeting of the same title held June 25, 2009,
in Washington, DC, sponsored by the USAID Interagency Youth Working Group. Those who
contributed to planning that meeting were Debbie Kaliel, Shanti Conly, and Jenny Truong, USAID;
Linda Wright-Deaguero, U.S. Centers for Disease Control and Prevention; Karina Rapposelli,
U.S. Office of Government AIDS Control; Diane Widdus, UNICEF; Mary Otieno, Jenny Butler, and
Koye Adeboye, UNFPA; Bruce Dick, WHO; and Joy Cunningham, Karah Fazekas, Bill Finger, and
Elena Lebetkin of FHI.

FHI coordinated the editorial process for this paper, led by Bill Finger with assistance from Suzanne
Fischer, Jan Wheaton, Elizabeth Futrell, and Elena Lebetkin. Design by Hopkins Design Group Ltd.

* These people were with the organization indicated at the time of the June 2009 meeting, but they
have since moved to other organizations.

This publication does not necessarily represent the views, decisions, or policies of the U.N. agencies
involved in the UNAIDS Inter-Agency Task Team on HIV and Young People, which supported the
development of this document. This document is made possible by the generous support of the
American people through the U.S. Agency for International Development (USAID). The contents are
the responsibility of FHI and do not necessarily reflect the views of USAID or the United States
Government. Financial assistance was provided by USAID under the terms of Cooperative Agreement
No. GPO-A-00-05-00022-00 and the Preventive Technologies Agreement No. GHO-A-00-09-00016-00.

© FHI, 2010

ISBN: 1-933702-62-1

Table of Contents

Introduction 1

Chapter 1. Framing the Issue: Young People, Risk,
Vulnerability, and the HIV Epidemic 5
Understanding Young People 7
Most-at-Risk Young People 9
Vulnerability and Young People 13
Programs for Most-at-Risk Young People 15
Program Challenges 19

Chapter 2. Young Men Who Have Sex with Men 27
Vulnerability and Risk 29
Programmatic Approaches 33
Conclusions and Next Steps 36

Chapter 3. Young People Who Sell Sex 41
Programmatic Approaches 47

Chapter 4. Young People Who Inject Drugs 59
Programmatic Approaches: Demand Reduction 63
Programmatic Approaches: Harm Reduction 65

Young People Most at Risk of HIV page i

Chapter 5. Conclusions 73

Appendix 1: Meeting Agenda 84

Appendix 2: References 87

Figures Figure 1. An Ecological Model of Young People’s
Health and Development 8
Figure 2. Continuum of Volition 48
Figure 3. Projected Total Number of HIV Infections in Various
Population Groups, 2000–2020, in Jakarta, Indonesia 61
Figure 4. First-Injection Helpers 64

Tables Table 1. Risk Behaviors for HIV, STIs, and Pregnancy 9
Table 2. What Makes Some Young People Vulnerable to
Becoming Most at Risk? 14
Table 3. Combination Prevention for Most-at-Risk Young People 18
Table 4. Roles of UN Agencies in HIV Prevention
among Young People 23

Sidebars Consultation on Strategic Information and HIV Prevention
among Most-at-Risk Adolescents 11
Young People’s Participation: A Key Asset for Those
Most at Risk 16
Youth and HIV: Which Agencies Do What? 22
Trafficking 46
Family Planning and Reproductive Health 49
Transactional and Nonconsensual Sex 54
Beyond HIV Prevention 70

page ii Young People Most at Risk of HIV

Introduction


T
his paper is designed to call more attention to young people
within the groups considered “most at risk” for HIV—those
who sell sex, those who inject drugs, and young men who have
sex with men. Despite the growing attention that has been given to
programming for these groups, little explicit focus has emerged on
the particular needs of young people in these populations. At the
same time, efforts to prevent HIV among young people have tended In this report the following
to focus on the general population of young people, for whom more definitions are used:
is known about effective programming, instead of focusing on young adolescents, which refers to
people in most-at-risk groups. As a result, young people who inject individuals between the ages
drugs or sell sex and young men who have sex with men are often not of 10 and 19; youth, which
targeted in either type of programming. refers to individuals between
the ages of 15 and 24;
Research has begun to show the importance of focusing on young and young people, which refers
to those between the ages
people within most-at-risk populations, and there are increasing
of 10 and 24. If the text does
examples of programmatic approaches for meeting their needs. But not specify a particular
many challenges remain, including the fact that there are significant age group, it refers to all young
differences among young people between the ages of 10 and 24. people, i.e., individuals
For example, the United Nations has stressed that the term sex worker between the ages of 10 and 24.
can apply only to those at least 18 years of age because younger
adolescents are considered to be victims of commercial sexual
exploitation. In addition, much more work is needed to understand
the intersection of programming between young people in general
and young people most at risk of HIV and other sexual and repro-
ductive health (RH) problems.

On June 25, 2009, the U.S. Agency for International Development
(USAID) sponsored a daylong meeting in Washington, DC, entitled
“Young People Most at Risk for HIV/AIDS,” working through
the Interagency Youth Working Group led by FHI. The UNAIDS

Young People Most at Risk of HIV page 1

Inter-agency Task Team on HIV and Young People (IATT/YP) participated in the
planning of the meeting through its working group on most-at-risk young people.
The meeting had three objectives:

1. To provide an overview of the specific needs of young people (between
the ages of 10 and 24) who are vulnerable and most at risk of HIV

2. To provide examples of policies and programs that are designed
specifically to address the needs of most-at-risk young people

3. To identify the next steps in addressing the needs of vulnerable and
most-at-risk young people

The meeting was the first time that the UN and the key groups in the United States
that are responsible for administering the President’s Emergency Plan for AIDS
Relief (PEPFAR) had come together to share information and explore future
directions regarding policies and programs for young people most at risk of HIV.
The IATT/YP working group on most-at-risk young people had previously held
two meetings, one in Ukraine (Kiev) in 2006 and the other in Vietnam (Hanoi) in
2007. Both of these meetings focused on developing plans and sharing experiences
in selected countries (Brazil, Iran, Pakistan, Ukraine, and Vietnam participated)
to accelerate action for meeting the needs of young people most at risk of HIV.

Debbie Kaliel of USAID introduced the meeting by highlighting some of the
challenges of conceptualizing and responding to the needs of young people who are
vulnerable and most at risk of HIV infection. “The spectrum ranges from street
youth who are engaged in sex work and injecting drugs, which may take place in
both concentrated and generalized epidemics, to the significant risk of HIV faced
by many adolescent girls in countries with generalized epidemics. Understanding
risk within a context of vulnerability helps us to be clear about what we need to
be doing, and for whom. Concentrating this meeting on the three traditional most-at-
risk populations groups provides some focus and suggests some conceptual
models that may provide us with guidance.”

page 2 Young People Most at Risk of HIV

Even within this more narrow focus, Kaliel pointed out, there are tough questions
to address. “Do we need to include a focus on young people into programming for
most-at-risk populations, or should we give more attention to most-at-risk young
people in on-going youth programs?” she asked. “Or should we create separate
programs for most-at-risk young people?”

Based on the June 2009 meeting and additional material from literature reviews
and field experiences, this paper is designed to promote greater awareness and
attention to the needs of most-at-risk young people among donors, policymakers,
program planners, and others. It does not attempt to provide a systematic review
of all the available literature related to the topic, nor does it provide specific
programmatic guidance. It does, however, include suggested actions based on the
presentations and discussions at the June meeting and on the other materials
synthesized in this report.

The paper has the same structure as the June meeting (see Appendix 1: Agenda,
“Young People Most at Risk for HIV/AIDS”). The first chapter frames the issue and
discusses the unique characteristics of young people most at risk of HIV, the
concept of vulnerability, and the implications for programmatic approaches. It
includes several boxes on related topics, such as the roles of different UN agencies
and the importance of involving most-at-risk young people in developing and
implementing programs that meet their needs. This first chapter introduces several
themes that are common across the three subsequent chapters that focus respec-
tively on young men who have sex with men, young people who sell sex, and young
people who inject drugs. A concluding chapter summarizes key themes and
suggested next steps. Appendix 2 provides a summary of overall resources on this
topic, complementing those resource materials referenced in the footnotes of the
preceding chapters.

Young People Most at Risk of HIV page 3

Chapter 1.
Framing the Issue:
Young People, Risk, Vulnerability,
and the HIV Epidemic

M illions of young people around the world face a
high risk of infection from HIV and other negative
sexual and reproductive health (RH) outcomes as a result of
behaviors that they adopt, or are forced to adopt. Three groups
of young people who are considered to be most at risk of HIV
are young men who have sex with men and young people who
sell sex or inject drugs. In addition to these three groups, other
young people are also at higher risk of infection, especially
in generalized epidemics. Those who have sex with someone
who is or is likely to be HIV-infected are at risk of acquiring
HIV if they do not use a condom. This broad group includes
the clients of sex workers, the wives of these clients, an HIV-
negative partner in a discordant couple, and, in high prevalence
settings, adolescent girls who have sex with older men. All of
these groups include substantial numbers of young people.

Chapter 1. Framing the Issue: Young People, Risk, Vulnerability, and the HIV Epidemic page 5

HIV programs and policies have in general failed to respond to the specific needs
of young people in most-at-risk populations. Such programming is challenging
because related data are usually not disaggregated by age, and there are few good
examples of effective programs to provide inspiration and guidance. Furthermore,
these are often not discrete groups because the behaviors frequently overlap—for
example, young people who inject drugs might sell sex to buy drugs, and sex workers
might inject drugs to provide some escape from their situation.1 Improving our
response to HIV prevention and care among most-at-risk young people could play
a pivotal role in strengthening national HIV programs.

Consistently using condoms and clean injecting equipment greatly reduces the
risk of HIV infection among these groups. But the young people who most need
such protection often have the most difficulty accessing appropriate services and
adopting behaviors that protect them from HIV. The behaviors that put them at risk
are usually heavily stigmatized and take place clandestinely, often illegally.2 Existing
policies and legislation, lack of political support, and other structural issues often
prevent most-at-risk young people from receiving the services that they need.
Such factors contribute to marginalizing these young people further, which then
contributes to undermining their self-efficacy, their confidence in health and social
services, and their willingness to make contact with service providers.

To help frame the discussion about young people who are most at risk of HIV and
other sexual and RH issues, this chapter first summarizes key factors that mark the
period of adolescence, i.e., the factors that make adolescents different from small
children and adults. Second, it discusses the term most at risk in more detail, defines
the behaviors that put some young people more at risk of acquiring HIV, and
synthesizes the data that are available to help understand the importance of these
populations in the HIV epidemic. Third, the chapter addresses the broader concept
of vulnerability and outlines those factors that make some young people particu-
larly vulnerable to becoming most at risk of HIV. Finally, it discusses programmatic
approaches for most-at-risk young people and introduces issues that are discussed
in more detail in the chapters that follow.


Understanding Young People
The period between childhood and adulthood includes a wide age range and
significant variations between and within individuals in terms of the physical,
psychological, and social development that takes place. Besides their age, factors
such as marital status and economic independence have implications for how
society views young people and how they view themselves. Adolescence is the
time when puberty takes place, when the majority of people initiate sex, and when
sexual preference and identity are formed. Many characteristics of young people
need to be taken into consideration in both the content and delivery channels of
services that are provided for them. These characteristics include their age and
sex, whether or not they are in school, their family relationships and support, and
where they live (i.e., in rural or urban areas). Programmers need to be aware of
such factors and, at the same time, be able to capitalize on the vibrancy, innovation,
and sense of hope that is inherent in many young people.

During the second decade of life, adolescents make important transitions, which
often include not only sexual initiation but also leaving school, entering the labor
force, forming partnerships, and having children.3 This is a period of first-time
experiences, risk-taking, and experimentation with many things, including alcohol
and other psychoactive substances. Many things, including the fact that their
capacity for complex thinking is still developing, affect how young people deal with
the opportunities and challenges that surround them.4

The changes that take place during adolescence need to be understood by the people
who are responsible for HIV programming because these changes affect:

n How adolescents understand information

n What information and which channels of information influence
their behavior
n How they think about the future and make decisions in the present

n How they perceive risk in a period of experimentation and
first-time experiences
n How they form relationships, respond to the social values and
norms that surround them, and are influenced by the attitudes (or
perceived attitudes) of their peers and others


Figure 1. An Ecological Model of Young People’s
Health and Development

Social Values

Service Providers

Peers

Family

Adolescent

Community Leaders

Policies

The World Health Organization (WHO), the United Nations Population Fund
(UNFPA), and United Nations Children’s Fund (UNICEF)5 have grouped young
people’s needs for health and development into four priority areas: comprehensive
information and life skills; services, including counseling and commodities; safe
and supportive environments; and opportunities for participation. These needs are
for the most part also defined as rights in the Convention of the Rights of the Child.
Many people need to be involved in meeting these needs, including parents or
guardians, peers, teachers, service providers, community and religious leaders, and
policymakers. The ecological model in Figure 1 provides a synthesis of the many
different actors and determinants that have an impact on the health and
development of young people.


At an individual level, many factors affect young people’s health. In terms of HIV,
young people are less likely to be able to prevent themselves from becoming infected.
They often do not have sufficient correct knowledge about HIV, the skills to use the
knowledge that they do have (to negotiate condom use, for example), or access to the
services and commodities that they need. Broader factors include the role of parents
and the community, as well as social values and norms. Studies from more than 50
countries have identified a number of common determinants that are associated with
behaviors that could undermine adolescents’ health, such as early sexual activity and
substance use.6 These determinants could either increase the risk of negative behav-
iors (risk factors) or protect against them (protective factors). They include the young
person’s relationship with his or her parents and other adults in the community,
family dynamics, the school environment, the attitudes and behavior of friends, and
spiritual beliefs. Protective factors in preventing early sexual debut are a positive
relationship with parents, a positive school environment, and spiritual beliefs. Risk
factors associated with early sexual debut include having friends who are negative
role models and engaging in other risky behaviors, such as substance use.7

Most-at-Risk Young People
Two behaviors pose the greatest risks for the acquisition of HIV: penetrative sex
(vaginal or anal) with multiple partners without using condoms, and sharing
infected needles and syringes to inject drugs. Unprotected vaginal sex is a risk not
only for HIV, but also, of course, for pregnancy (see Table 1).

Table 1. Risk Behaviors for HIV, STIs, and Pregnancy

Risk Behaviors HIV STIs Pregnancy

Vaginal sex without a condom yes yes yes

Anal sex without a condom yes yes NA

Frequency of sex is important,
Multiple partners yes yes
but not the number of partners

Other diseases
Injecting drugs with are associated with
yes NA
shared equipment injecting drugs,
such as hepatitis


Some groups of young people are most at risk of HIV because they adopt, or are
forced to adopt, behaviors, which, if practiced unsafely, might put them at risk of
becoming infected with the virus: young men who have sex with men, young
people who sell sex, and young people who inject drugs. Even for these groups, a
number of factors affect the degree of risk, including the frequency of the risk
behavior, the likelihood of HIV exposure associated with the behavior (e.g., the
prevalence of HIV among sexual partners and those using the same injecting
equipment), and the likelihood of infection if exposed (e.g., anal sex is a higher-risk
behavior than vaginal sex).

In terms of the epidemiology of HIV, most-at-risk populations are particularly
important in concentrated epidemics, although they also require consideration in
generalized epidemics.8 In regions where concentrated epidemics are common,
the most-at-risk groups represent a large percentage of those living with HIV: 76
percent in Eastern Europe/Central Asia, 35 percent in South and Southeast Asia
(India excluded), and 49 percent in Latin America.9 If the clients of commercial
sex workers are also included, then the percentage of overall infections attributable
to most-at-risk groups jumps to 83 percent in Eastern Europe/Central Asia, 76
percent in South and Southeast Asia (India excluded), and 62 percent in Latin
America. The clients of sex workers who also have sex with their wives and
girlfriends might transmit HIV through unprotected sex, which links most-at-risk
groups with the general population. A similar process can occur with the sexual
partners of drug users10 and the female sexual partners of men who have sex with
men (MSM).


Consultation on Strategic Information and HIV Prevention
among Most-at-Risk Adolescents
In collaboration with the Inter-Agency Task Team on HIV and Young People, UNICEF held a Consultation
on Strategic Information and HIV Prevention among Most-at-Risk Adolescents (between the ages of
10 and 19) in 2009. The Consultation provided a forum for the exchange of information on country-level
data collection and programming targeted at most-at-risk adolescents with the goal of identifying
tactics for employing strategic data to improve HIV prevention among these adolescents and building
support for programming among decision makers to help these young people.

The report from the consultation offers recommendations to address research and programming
challenges specific to these adolescents. These challenges include the following:
n The difficulty in reaching these adolescents
n Legal and ethical concerns
n Weak collaboration and coordination efforts
n Conflicting agendas among agencies
n Lack of political and social support
n Information gaps as barriers to effective programming

The report identifies 10 key actions to broaden the evidence base, strengthen political commitment,
and expand links across sectors. The report also offers detailed suggestions for national, regional,
and global efforts to support each of these actions. The actions are shown below as they are grouped
in the report.

Improving the collection and analysis of strategic information
n Systematically disaggregate data on most-at-risk populations by age group:
15-19, 20-24, and 25 and over.
n Strengthen capacity and willingness to estimate population size of
most-at-risk adolescents.
n Improve data collection coordination and approaches.

Generating political support for policies and programs
n Integrate most-at-risk adolescents into existing systems, publications, and reports.
n Support a cyclical approach: research to advocacy to programming to advocacy
to implementation.
n Foster productive partnerships.

Building links and strengthening partnerships across sectors and services
n Use evidence to promote a multi-sectoral response.
n Work with existing systems and processes and encourage parallel, mutually
supportive approaches.
n Strengthen knowledge management.
n Expand partnerships.


Programs seeking to prevent the spread of HIV use the phrase “know your epidemic
and response.”11 When considering most-at-risk groups, knowing the epidemic
includes understanding the crucial role that young people play in the transmission
of HIV. Not only do young people constitute a large percentage of most-at-risk
groups, but they also frequently have higher HIV infection rates within these
groups.12 An estimated 70 percent of the world’s injecting drug users are under the
age of 25.13 A study of injecting drug use (IDU) in cities around the world found that
between 70 and 95 percent of users had started before the age of 25. In most of the
cities, at least half had started injecting between the ages of 16 and 19, and some had
started even younger.14 In many places, a significant proportion
of women in sex work start before they reach age 20, with the
majority of sex workers being under the age of 25.15
Not only do young
people constitute a large
Regarding rates of HIV infection among most-at-risk young people,
percentage of most-
at-risk groups, but they in Myanmar, for example, the highest HIV rates among female sex
also frequently have workers and those injecting drugs occurred in the 20- to 24-year-
higher HIV infection rates old age group (41 percent and 49 percent, respectively), with
within these groups. rates in the 15- to 19-year-old age group also being very high
(41 percent and 38 percent).16 In some places, young sex workers
are more likely to inject drugs17 and less likely to use condoms
than older sex workers.18 In the United States, the number of infections among MSM
increased from 2001 to 2006 only among those in the 13- to 24-year-old age group,
while the numbers have either declined or stayed the same among other age groups.19

In summary, young people comprise a significant proportion of most-at-risk popula-
tions, and they often have higher HIV prevalence than older people in these groups.
Therefore, the following factors need to be considered when developing programs:
n Young people’s behavior is less fixed than adults’ behavior. Drug
use and particular sexual practices are sometimes experimental and
might or might not continue.
n Young people are less likely than older adults to identify themselves
as drug users or sex workers. This makes them harder to reach with
programs and less responsive to communication addressed to groups
with specific identities.
n Young people are more easily exploited and abused.

n Young people have less experience coping with marginalization
and illegality.


n Young people might be less willing to seek out services, and service
providers might be less willing to provide services to them because
of concerns about the legality of behaviors in some settings and
informed consent.
n Young people are often less oriented toward long-term planning and
thus might not think through the consequences of the risks that are
related to the choices they make.

Vulnerability and Young People
The behaviors of some young people, such as selling sex or injecting drugs, put
them at high risk of HIV infection. But clearly not all young people adopt these
behaviors, and even among those who do adopt them, some use condoms or clean
needles and syringes, and some do not. As a report from the Joint United Nations
Programme on HIV/AIDS (UNAIDS) explains, most at risk refers to behaviors,
while vulnerability refers to the circumstances and conditions that make most-at-risk
behaviors more likely.20 Many of these conditions are beyond an individual
young person’s control, and they are often referred to as structural factors or the
risk environment.21

Young people are more vulnerable to HIV infection because of the societal factors
that reduce their ability to avoid risky behaviors.
n They might not have access to information and services.

n They might be living without parental guidance and support.

n They might have been trafficked or exposed to physical or sexual
violence and abuse.
n They might live in societies where laws or social values force young
people to behave in ways that place them at risk, for example,
homophobia or norms that encourage adolescent girls to have sex
with older men.

Young people become more vulnerable if their health and development needs are
not met, i.e., if they do not have access to information and services, do not live and
learn in environments that are safe and supportive, and do not have opportunities
to participate in the decisions that affect their lives. Table 2 provides examples of
some of the factors that can cause young people to become vulnerable and adopt
most-at-risk behaviors.


Table 2. What Makes Some Young People Vulnerable to Becoming Most at Risk?

Young people’s Factors that make young people vulnerable and likely to adopt
needs most-at-risk behaviors

n Lack of access to age-appropriate information through schools,
Access to information the media, and other sources
and opportunities n Not being in school
to develop life skills n Lack of opportunities to develop self-efficacy

n Lack of services that meet their specific needs
n Families and communities that oppose or fail to support young people
using services
Access to services
n Laws and policies that restrict access to services by young people
(e.g., requirements for parental consent)

n Lack of family attachment, parental guidance, and family support, e.g.,
orphans and young people in institutions and poorly functioning families
Supportive and n Living in situations of marginalization, discrimination, exploitation,
safe environments abuse, poverty, and easy access to drugs
n Homelessness and lack of access to safe spaces

n Lack of community organizations working with and for young people
Participation in the
n Lack of opportunities to participate in programs that affect their health
making of decisions
that affect their lives n Few advocacy/activist organizations that involve and engage
young people


The term especially vulnerable young people refers to those whose living conditions
are particularly likely to lead them to adopt most-at-risk behaviors. These conditions
include living on the street or as an orphan, in a correctional facility, in a family
or community where drug use is common, in a family where there is physical or
sexual abuse, in extreme poverty, in areas where human trafficking is common,
in displacement or migration, in war or conflict situations, or with disabilities.

In the hyper-endemic countries of southern Africa, all girls and young women
could be considered to be especially vulnerable.22 In countries with HIV prevalence
above 15 percent, women between the ages of 15 and 24 are two
to four times more likely to be infected than men in the same age
In countries with HIV
group, largely because of age-disparate sex. The greater the age
prevalence above
difference between sexual partners, the greater the likelihood that 15 percent, women
the woman will become infected. Given the lack of livelihoods for between the ages of 15
young women and the imbalance of power, sex with older men and 24 are two to
is often transactional, coerced, or even forced.23
Regardless of the four times more likely to
degree of volition, however, these young women face a high risk be infected than men
in the same age group.
of HIV infection.

Programs for Most-at-Risk Young People
All young people should receive information, life-skills development, and HIV
prevention services and commodities, including services related to sexual and
reproductive health. For especially vulnerable young people, programs should
include all of the activities and services provided to the general population of
adolescents plus actions that are designed to mitigate individual vulnerability.
These actions should include counseling and protection from abusive or exploit-
ative situations, and they should address structural determinants, such as
alleviating poverty and changing harmful social values and norms, including
gender norms.

Young people who have already engaged in behaviors that put them at risk of HIV
infection (a subgroup within the especially vulnerable group) need all of the
services provided for the general population of young people and those provided
for vulnerable young people. In addition, they need programs to reduce the risk
and the related harm of the behaviors that they have adopted, as well as support to
stop these behaviors.


Young People’s Participation: A Key Asset for Those Most at Risk
Programs and services for young people can benefit from including them in the design, implementation,
and delivery of services. Over the last decade, more youth–adult partnerships and youth-led
programming have been incorporated into general HIV and RH programming for young people. But
youth participation in programs for most-at-risk young people creates extra and, at times, formidable
hurdles, and requires greater advocacy from both young people and adults.

Support for harm-reduction programs for young people is not widespread, and high-level leadership
is lacking. Meanwhile, many health programs and providers are fearful about serving adolescents. What
can young people and their adult allies do about this situation?

Raising awareness is the first task, starting with people concerned about HIV and about young people.
Health care providers, policymakers, educators, and advocates need to hear young people’s first-hand
experiences as providers and as clients of harm-reduction services. Participation in national, regional,
and international meetings can help, but is difficult to arrange for those young people who are most at
risk. Meaningful participation of most-at-risk young people requires that adult mentors and service
providers supply a significant amount of financial and programmatic support. Meaningful engagement
with these young people is a process that takes time and resources.

Input from the intended program beneficiaries can help programs avoid making unfounded assumptions.
Involving young people can help those programs that lack experience working with young people who
are engaged in illegal activities, such as drug use. For instance, local service providers in Vancouver,
Canada, were convinced that they understood the needs of young people using drugs, and yet they had
never asked them what kind of services they wanted or needed. A program that was developed by and
for street-involved methamphetamine users, called Crystal Clear, sought to provide young people with
the services they wanted to have access to in their community. The program asked their peers and friends
about the what, when, where, and how of programming for young methamphetamine users. As the
group developed the program, they surveyed their peers, used focus groups, and shared the findings with
local service providers. As a result, the providers changed the ways they were reaching the young people.

Youth RISE (Resource, Information, Support, and Education) is the leading youth-led international
organization dedicated to harm reduction among young people. Their work includes facilitating the
involvement of young people in conferences and meetings at international and local levels to participate
in policy change. Youth RISE also trains young people to carry out harm-reduction and youth-engagement
activities and develops and distributes evidence-based information on young people, substance use, and
harm reduction. Youth RISE and other groups seek to engage young people in decision-making processes,
research, and training initiatives in order to develop programs that will work with young people who may
use drugs. Peer-to-peer contact has proved to be an effective way to reach most-at-risk young people—
sometimes it is the only way. When young people themselves are providing services, young clients feel
more connected to the program, and they are more likely to stay engaged.

Youth RISE emphasizes that one program model does not fit all situations. A practice developed in one
place might need to be tested and adapted before it can work elsewhere. With the help of young people
themselves, programs can get to know their clients and develop programs that meet the needs that
these young people are expressing.


Risk-reduction programs seek to support young people in avoiding behaviors that
put them most at risk. These programs focus on preventing young people from
selling sex or from using psychoactive substances, including injecting drugs.
Program initiatives might include the following:
n Access to education

n Livelihood skills training and employment for vulnerable girls

n Prevention of trafficking and other means of sexually exploiting
young girls
n Programs to decrease drug use in families and in places that
young people frequent

Some refer to these efforts as primary prevention. Risk-reduction programs are
not relevant or appropriate for preventing young men from having sex with other
young men through choice because this is a matter of sexual orientation.

Harm-reduction programs address the needs of young people who have already
adopted behaviors that put them most at risk of HIV. The first priority is to reduce
the chances of HIV infection inherent in these behaviors. This can be done by
ensuring that young people use condoms correctly and consistently when engaging
in penetrative vaginal or anal sex, especially with multiple partners, or by ensuring
that those who are injecting drugs use clean needles and syringes.

Beyond specific risk-reduction and harm-reduction programs,
young people need expanded options and opportunities that will HIV prevention programs
have the long-term effect of reducing harm, risk, and vulnerability. for the general population
For any of the above approaches to succeed, a number of of young people might
different types of programs will be needed, including biomedical, consider most-at-risk young
behavioral, and structural components. This is known as people, particularly
those injecting drugs and
combination prevention. Table 3 provides some examples of
selling sex, as outside their
combination prevention for most-at-risk young people.
expertise and outside their
sphere of responsibility.
For most-at-risk young people, these types of combination
efforts are particularly important. Many programs focus on
biomedical and behavioral components. Structural factors
are equally important but often receive less attention for a number of reasons,
including the fact that the evidence base for effectiveness is less strong and the
programs are often more complex and long-term. For example, gender norms and


Table 3. Combination Prevention for Most-at-Risk Young People

Type of intervention Strategy Examples

Directed to individuals to Providing condoms, drug substitution, treatment
Biomedical
decrease risk for sexually transmitted infections (STIs)

Providing information and life skills through
schools, workplace, and community-based
Directed to individuals and
organizations; needle exchange programs
Behavioral their environments,
(harm reduction); addressing social change
to decrease risk and vulnerability
programs that contribute to behavior through
the media and other channels

Increasing the number of schools, and
increasing enrollment and retention in schools;
increasing access to livelihood programs;
decreasing discrimination and marginalization;
Directed to individuals and changing policies and legislation that
Structural their environments, restrict access to services; engaging and
to decrease risk and vulnerability mobilizing young people who are vulnerable
and most at risk; addressing gender
norms and harmful cultural practices (such
as sexual violence) through policies and
social norms

related laws can deny young women education and livelihoods and can contribute
to conditions that allow young women’s commercial sexual exploitation, abuse,
and coercion.24 Other structural factors include criminalization and discrimination
against the behaviors that place some young people most at risk of HIV, and this
can create serious obstacles to most-at-risk young people who are seeking the
help that they need. Also, policies and laws could prevent minors from accessing
services without parental consent, which is often not realistic for most-at-risk
young people.


Program Challenges
Too often, most-at-risk young people fall into the gap between Many programs focus on
two different approaches to programming. HIV prevention biomedical and behavioral
programs for the general population of young people might components. Structural
consider most-at-risk young people, particularly those injecting factors are equally important
drugs and selling sex, as outside their expertise and outside their but often receive less
attention for a number of
sphere of responsibility. At the same time, programs for most-
reasons, including the
at-risk populations rarely adapt their service delivery to take into
fact that the evidence base
account the unique needs and circumstances of young people for effectiveness is less
who are most at risk of HIV, especially adolescents. strong and the programs
are often more complex
Widening this gap, resources for HIV prevention among young and long-term.
people frequently do not go where they can have the most
impact in terms of preventing new infections. For example, in
Asia, where concentrated epidemics predominate, at least nine
out of every 10 newly infected young people come from most-at-risk groups,
but the allocation of prevention resources is the reverse. According to the Asia
Commission on AIDS, over 95 percent of all new HIV infections among young
people occur among most-at-risk young people in Asia. Yet more than 90 percent of
resources for young people as a target group are spent on low-risk youth, who account
for less than five percent of infections. Countries must better track and analyze
the information on high-risk populations and allocated resources accordingly.25

Most-at-risk young people are among society’s most marginalized groups. They
generally have few connections with social institutions, such as schools and organized
religion, where many youth programs are provided. Furthermore, programs for
most-at-risk young people often face explicit hostility, such as
police harassment of young clients who come to needle and
syringe exchange programs. In most societies, the prevailing
Most-at-risk young people
reaction to most-at-risk behavior is to try to prevent and punish
are among society’s
it, and these attitudes are even more entrenched when it comes
most marginalized groups.
to thinking about adolescents. Harm-reduction programs appear
to some people as tolerating or even aiding illegal behavior. As a
result of this hostile environment, programs for most-at-risk
young people often spend much of their energy fending off opposition and
lobbying for policy change. So programs face hard choices in balancing the energy
needed to overcome these obstacles with that required to provide the services that
their clients need for HIV prevention.


Young people below the age of 18 are considered to be children under the United
Nations Convention on Rights of the Child. This establishes the obligation to remove
these young people from exploitative situations, for example sexual exploitation, and
to provide them with appropriate health, legal, and social services in accordance
with their best interests and evolving capacities. Governments also have obligations
to provide the information and services that are necessary to help reduce the harm
from the risks that these young people face. Advocates need to ensure that laws and
policies that are intended to protect the rights of most-at-risk adolescents do not end
up preventing them from receiving the programs that they need.

A review of services for most-at-risk young people found that outreach by peers
has often proven to be the best way of making contact with them.26 Programs must
work closely with young people, engaging them as partners in planning and
learning from them about reaching young people with services (see box, Young
People’s Participation: A Key Asset for Those Most at Risk, page 16).

Some of the core elements for developing a more effective response to young people
who are most at risk of HIV include the following:
n Collecting and disaggregating data by age, in addition to sex,
which is important for advocacy, policies, and the development and
monitoring of programs
n Developing and implementing policies that protect vulnerable young
people, decriminalizing the behaviors that place them most at risk,
and ensuring that most-at-risk adolescents can access the services
that they need
n Training services providers, both those who work with most-at-risk
populations and those who work with vulnerable groups of young
people, so that they are better able to meet the specific needs of
most-at-risk young people
n Making effective links between services and communities: with
parents, schools, youth, civil society, religious and community
leaders, and others
n Involving young people as advocates and as peers to make
contact with, and provide outreach to, vulnerable and most-at-risk
young people


Developing robust, effective programs that reach most-at-risk young people
requires more attention from major donors. Both the United Nations (UN) and the
U.S. government, through PEPFAR, have begun to address this challenge (see box
on page 22, for a summary of the agencies involved). The UNAIDS Inter-agency
Task Team (IATT) on HIV and Young People consists of all relevant UN agencies
and involves a number of other organizations including civil society, donors, and
youth organizations. The IATT has formed a working group on most-at-risk young
people. This group is developing guidance on programming and case descriptions
of good practice about most-at-risk young people.

PEPFAR currently does not have a specific strategy group or position paper that
addresses the problem of most-at-risk young people. PEPFAR does, however, have
an interagency technical working group that focuses on most-at-risk populations
in general, and it has developed guidance for a minimum package of services.
The package includes community-based outreach and education, access to sterile
needles and syringes and safe disposal, condoms, STI screening and treatment,
voluntary HIV counseling and testing, and addiction treatment. The guidance also
includes HIV care and treatment, access to prevention of mother-to-child trans-
mission (PMTCT), tuberculosis screening and treatment, and access to health and
social services such as case management, family planning, and income generation.

This PEPFAR working group is beginning to discuss how this minimum package
of services can more directly address the specific needs of young people. Some U.S.
funding for programs with most-at-risk populations includes an explicit focus on
young people, including improved access to youth-friendly clinics, peer outreach,
and opportunities for job-skills training and education. The working group plans
to focus more attention on young people, including age- and sex-disaggregated
reporting of data. Such data can support operational research to determine what
services are needed and how to deliver them, and to involve young people in all
aspects of programming. All of these goals will require monitoring, including
monitoring by youth advocacy groups, in order to ensure that such steps can be
sustained in the face of the major HIV prevention challenges facing programs for
most-at-risk young people, especially adolescents.


Young People and HIV: Which Agencies Do What?
Funding for HIV prevention within the U.S. government comes through PEPFAR.
Coordination of this funding is the responsibility of the Office of the U.S. Global AIDS
Coordinator (OGAC), which is part of the Department of State. The primary agencies
implementing the PEPFAR program are USAID; the Centers for Disease Control and
Prevention (CDC); the Peace Corps; and the Departments of State, Defense, Commerce,
Labor, and Health and Human Services (see http://www.pepfar.gov/agencies/index.htm).

Within PEPFAR, an interagency Technical Working Group focuses on prevention for
most-at-risk populations, with a subgroup focusing on substance abuse. The working
group seeks to share scientific and programmatic information to improve service
delivery for most-at-risk populations, to provide technical assistance to PEPFAR country
programs, and to review prevention programs. A separate Technical Working Group
addresses prevention for the general population and young people, including
contextual factors that increase young people’s vulnerability to HIV. Neither of these
working groups focuses explicitly on young people most at risk of HIV.

The United Nations agencies have agreed on a UNAIDS technical division of labor
concerning HIV prevention and young people. The agencies take both lead and
partnership roles as shown in Table 4.

In 2001 the Joint United Nations Programme on HIV/AIDS (UNAIDS) formed the IATT on
HIV and Young People to foster joint accelerated, harmonized, and expanded responses
at the country level. UNFPA serves as the convener of this task team. In May 2008,
membership expanded to include partners from civil society, academic institutions,
youth networks and associations, the private sector, and other development
organizations. Information can be found online at http://www.unfpa.org/public/site/
global/lang/en/iattyp. Within the IATT on HIV and Young People, the Working Group
on Most-at-Risk Young People, which is convened by UNICEF, strengthens collaboration
and consensus among participating agencies and organizations to support action at
the country level.


Table 4. Roles of UN Agencies in HIV Prevention among Young People*

UNAIDS Secr.

World Bank
Technical support areas of

UNESCO
HIV prevention activities

UNODC
UNICEF
UNHCR
UNFPA
UNDP

WHO
WFP
ILO
IDU and prisoners P P P P P P L P

MSM P L P P P P

Sex workers P P P L P P P P

Vulnerable groups P P L P P P P

Displaced populations P P P L P P P

Workplace policy/progs. L P P P

Health sector response P P P P P P P L

Young people in
P L P P P P P P P
education institutions

Young people out of school P P P L P P P

L = lead agency, P = main partner agency, IDU = injecting drug use,
MSM = men who have sex with men

* ILO = International Labour Organization; UNAIDS = Joint United Nations Programme
on HIV/AIDS; UNDP = UN Development Programme; UNESCO = UN Educational,
Scientific, and Cultural Organization; UNFPA = UN Population Fund; UNHCR = UN
Refugee Agency; UNICEF = UN Children’s Fund; UNODC = UN Office on Drugs
and Crime; WFP = UN World Food Program; WHO = World Health Organization.

Source: UNAIDS Inter-Agency Task Team on HIV and Young People.
Global Guidance Briefs: HIV Interventions for Young People. New York: UNFPA, 2008.


Chapter 1. Notes

1 UNAIDS. 2008 Report on the Global AIDS Epidemic. Geneva, UNAIDS, 2008; Nguyen, TA, Oosterhoff,
P, Hardon, A, et al. A hidden HIV epidemic among women in Vietnam. BMC Public Health 2008;8:37.

2 UNAIDS Interagency Task Team on HIV and Young People. Guidance Brief: HIV Interventions for
Most-at-Risk Young People. New York, UNFPA, 2008.

3 Juarez F, LeGrand T, Lloyd C, et al. Introduction: adolescent sexual and reproductive health in
Sub-Saharan Africa. Stud Family Plann 2008;39(4)239-44.

4 Steinberg, LD. Adolescence. 8th ed. Boston: McGraw Hill, 2008.

5 WHO, UNFPA, and UNICEF. Action for Adolescent Health: Towards a Common Agenda. Geneva:
WHO, 1997. http://www.who.int/child_adolescent_health/documents/frh_adh_97_9/en/index.html

6 WHO, Broadening the Horizon. Geneva: World Health Organization, 2001.
http://www.who.int/child_adolescent_health/documents/fch_cah_01_20/en/index.html

7 Blum RW, Mmari KN. Risk and Protective Factors Affecting Adolescent Health in Developing Countries.
Geneva: World Health Organization, 2004; Broadening the Horizon.

8 UNAIDS/WHO. Second Generation Surveillance for HIV: The Next Decade. Geneva: UNAIDS, 2000.
UNAIDS, UNICEF, UN, and USAID Web sites have similar definitions of generalized and concentrated
epidemics. All of them use a similar rule of thumb for a generalized epidemic: HIV prevalence over
one percent (some add specifications such as prevalence in pregnant women or mostly heterosexual
transmission). They also have a similar definition for concentrated epidemics: more than five percent in
at least one defined subpopulation and below one percent of the generalized population (or of pregnant
women).

9 UNAIDS. AIDS Epidemic Update 2006. Geneva: UNAIDS, 2006. India was excluded from the analysis
because the scale of its HIV epidemic, which is largely heterosexual, masks the extent to which other
at-risk populations feature in the region’s epidemic.

10 Wiessing L, Kretzchmar M. Can HIV epidemics among IDUs ‘trigger’ a generalised epidemic?
Int J Drug Policy 2003;14:99-102.

11 UNAIDS. UNAIDS Practical Guidelines for Intensifying HIV Prevention. Towards Universal Access.
Geneva: UNAIDS, 2007.

12 Monasch R, Mahy M. Young people: the centre of the HIV epidemic. In: Ross DA, Dick B, Ferguson J,
eds. Preventing HIV/AIDS in Young People. A Systematic Review of the Evidence from Developing Countries.
Geneva; World Health Organization, 2006.

13 UNAIDS. Report on the Global AIDS Epidemic 2004. Geneva: UNAIDS, 2004.

14 Malliori M, Zunzunegui MA, Rodriquez-Arenas A, et al. Drug injections and HIV-1 infection:
Major findings form the multi-city study. In: Stinson GV, Des Jarlais D, Ball AL, eds.
Drug Injecting and HIV Infection. Global Dimensions and Local Responses. London: UCL Press, 1998.

15 Monasch and Mahy, 2006.

16 Brown T. Chapter 5. The generation game: how HIV affects young people in Asia. In: AIDS in Asia:
Face the Facts. Monitoring the AIDS Pandemic Network (MAP), 2004, p. 86-89. Available at:
http://www.mapnetwork.org/docs/MAP_AIDSinAsia2004.pdf

17 Platt L, Rhodes T, Lowndes CM, et al. The impact of gender and sex work on sexual and injecting risk
behaviors and their association with HIV positivity among injecting drug users in the HIV epidemic in
Togliatti City, Russian Federation. Sex Trans Dis 2005;32(10):605-12.


18 Gray JA, Dore GJ, Li Y, et al. HIV-1 infection among female commercial sex workers in rural Thailand.
AIDS 1997;11(1):89-94.

19 US Centers for Disease Control and Prevention (CDC). Trends in HIV/AIDS diagnoses among men
who have sex with men, 33 states, 2001-2006. Morbidity and Mortality Weekly Report 2008;57(25):681-6.

20 UNAIDS. UNAIDS Practical Guidelines for Intensifying HIV Prevention. Towards Universal Access.
Geneva: UNAIDS, 2007.

21 Gupta GR, Parkhurst JO, Ogden JA, et al. Structural approaches to HIV prevention. The Lancet
2008;372(9640):764-75; Rhodes T. The ‘risk environment’: a framework for understanding and reducing
drug-related harm. Int J Drug Policy 2002;13:85-94.

22 Stirling M, Rees H, Kasedde S, et al. Addressing the Vulnerability of Young Women and Girls to Stop
the HIV Epidemic in Southern Africa. Geneva: UNAIDS, 2008; Bruce J. Girls Left Behind: Directing HIV
Interventions toward the Most Vulnerable. Transitions to Adulthood, Brief No. 23. New York: Population
Council, 2007.

23 UNICEF. Children and AIDS. Third Stocktaking Report, 2008. New York: UNICEF, 2008; Monasch,
Mahy.

24 Rao Gupta G, Parkhurst JO, Ogden JA, et al. Structural approaches to HIV prevention. Lancet
2008;372:764-75.

25 Commission on AIDS in Asia. Redefining AIDS in Asia. Crafting an Effective Response. New Delhi:
Oxford University Press, 2008.

26 Hoffmann O, Boler T, Dick B. Achieving the global goals on HIV among young people most at risk
in developing countries: young sex workers, injecting drug users and men who have sex with men. In: Ross
DA, Dick B, Ferguson J, eds. Preventing HIV/AIDS in Young People. A Systematic Review of the Evidence
from Developing Countries. Geneva: World Health Organization, 2006.


Chapter 2.
Young Men
Who Have Sex with Men

H IV infection has disproportionately affected men
who have sex with men (MSM) since the beginning
of the pandemic. In low-resource settings, MSM are on
average 19 times more likely to be infected with HIV than
the general population, and fewer than one in 20 MSM
have access to lifesaving HIV care.1 Stigma, discrimination,
homophobia, violence, and criminalization prevent MSM
from having access to and making use of the services that they
need for HIV prevention, treatment, and care. The coverage
of HIV prevention programs has generally increased in
low-income countries, but this has rarely benefited
MSM, particularly young men who have sex with men.

Chapter 2. Young Men Who Have Sex with Men page 27

Definitions related to this population are critical. The Asia Pacific Coalition on
Male Sexual Health (APCOM) captures the key issues in their definition of MSM:
“An inclusive public health term used to define the sexual behaviors of males
having sex with other males, regardless of gender identity, motivation for engaging
in sex, or identification with any or no particular ‘community.’ The words ‘man’
and ‘sex’ are interpreted differently in diverse cultures and societies as well as by the
individuals involved. As a result, the term MSM covers a large variety of settings
and contexts.”2 According to this definition, the term MSM can refer to:
n Men who identify themselves as gay, bisexual, or otherwise same-
gender oriented in sexuality and sexual practice
n Men who do not identify themselves as same-gender oriented,
but who have sex with other men because of economics
(e.g., sex workers), environments (e.g., prisoners), societal constraints
(e.g., gender separation, gender norms), experimentation (especially
for young men), or simply for pleasure
n Male-to-female transgender individuals who are male biologically,
but identify themselves as female and have sex with men

Studies on MSM report rapidly rising HIV infection rates in many areas. A recent
review of global HIV infection rates among MSM found high and increasing HIV
prevalence in Russia, China, and other parts of Asia. The review also summarized
the large number of epidemiologic studies that have recently established the
presence of populations of MSM throughout sub-Saharan Africa. The studies have
reported infection rates among MSM ranging from 12 percent in Tanzania to 31
percent in a township of Cape Town, South Africa. High HIV prevalence rates
among MSM were also seen throughout Latin America and the Caribbean.3

The impact of the epidemic on young MSM varies depending on the country.
Studies in Bangkok indicate HIV incidence among young MSM (between the
ages of 15 and 22) has nearly doubled in recent years, from 4.1 percent in 2003 to
7.7 percent in 2007, a faster increase than among older MSM.4 A study in Russia
reported young MSM (between the ages of 18 and 22) to have a significantly higher
HIV prevalence (7.7 percent) than the general population of MSM (5.7 percent).5
In contrast, a study from three African countries (Botswana, Malawi, and Namibia)
with established, more generalized epidemics, found higher rates among older
men: eight percent of MSM between the ages of 18 and 23 were infected compared
to 25 percent of those 24 and older.6 In the United States, where HIV programs


are widespread among older MSM, infection rates have recently increased “with
incidence rates approximately 10 times higher [among those ages between the ages
of 13 and 24] than that in the overall MSM community.”7 In particular, ethnic and
racial minorities have markedly higher rates among young MSM.

Vulnerability and Risk
An important risk factor for HIV infection for all MSM is
biological: transmission of HIV is five times more likely to occur In Africa, homosexuality
is illegal in most countries,
through unprotected receptive anal than through unprotected
and political and social
receptive vaginal intercourse.8 However, a number of other
hostility is endemic.
factors contribute to the risk for infection, especially for young
men, including stigma, discrimination, and criminalization,
which are reinforced in many cases by individual and cultural
homophobia. Other factors that could affect the degree of vulnerability for young
MSM include homelessness; abuse and victimization; substance abuse, including
amphetamine-type stimulants; and poor access to health and other services.

In Asia, according to a major 2006 report, male-to-male sex is illegal in 11 of the 23
countries surveyed. In many of the other 12 Asian countries, MSM are subject to
arbitrary persecution, often by police.9 The report explained that male-to-male sex
is widespread in Asia, but relatively few men adopt a Western-style gay identity in
which sexuality defines identity.

In Africa, a recent overview of research reports that homosexuality is illegal in
most countries, and political and social hostility is endemic.10 In Senegal, a mostly
Muslim nation where homosexuality is illegal, anti-gay demonstrators shouted
slogans at a protest outside Dakar’s main mosque after a gossip magazine published
photos of a gay wedding. A leading newspaper in Uganda ran a feature story with
photos and the headline “Top Homos in Uganda Named.”

Many sexuality education materials ignore the idea of same-sex orientation,
focusing instead on heterosexual issues. Not only do young MSM who are struggling
with their sexuality not get help from sex education, but in some instances they are
also harmed by the information they do receive. After exposure to HIV messages
focusing on vaginal intercourse, some young MSM report that they consider anal
intercourse to be safe. While clear information on HIV risk is important for
all MSM populations, it can be particularly influential during the second decade
of life when young people are establishing patterns of sexual behavior. A major


characteristic of sexual development during younger age is experimentation and
eventual establishment of sexual orientation and identity.

Dependence on family for economic support and educational pursuits often keeps
young MSM from disclosing their sexual identity and risky sexual behaviors.
If exposed, these young men are often disowned and must survive on their own.
Some might turn to sex work to survive. Young MSM are often left with many
questions and concerns, but with no support from family, peers, or other significant
adults in their lives, including teachers and service providers. In addition, the
relationships that they have with older men in some settings might not provide
them with the support that they need.

Young MSM are less likely to use protection during anal intercourse than older
MSM, according to some research. Below are summaries of studies that highlight
risk factors for HIV among young MSM, including the use of testing services to
know their HIV status.
n In Senegal, a study among 250 MSM found that the first sexual
encounter with a man occurred on average at age 15. This experience
was often with an adult, someone they knew or had recently met. For
about one-third of the sample, first sex was with an extended family
member. In some cases, initial sexual encounters with a man were
prompted by offers of money by an older man.11 A separate study in
Senegal found that 10 percent of MSM reported that their first sexual
encounter with a man was forced.12
n A formative research project by Population Services International
(PSI) and local partners in Togo, West Africa, trained 20 MSM as
peer researchers, conducted in-depth interviews and focus groups
discussions with them, and then broadened the research to 102
additional MSM. The average reported age of first sex with another
man was 17.6 years; about half had intercourse with a woman first.
About one-third reported having two or more concurrent partners, and
about half reported that they had been tested for HIV. While nearly
two-thirds reported using a condom at last intercourse with all men,
only 21 percent reported regular condom use with their regular male
partner. Some thought that HIV infection was transmitted through sex
with women, but not with men. “We are virgins because we’ve never
slept with women,” said one, “so we cannot catch that sickness.”13


n In China, a survey of 237 young men who had same-sex,
transactional sex for economic survival (called “money boys”)
focused on migrants from rural villages to Shanghai. About one-fifth
of the group self-identified as non-gay and the rest as gay. More than
half left home before the age of 20, many before the age of 15. The
gay-identified group was more likely to engage in anal sex and less
likely to use condoms. Depression prevalence was high in the study,
associated with stress, dissatisfaction with life, and prior or current
exposure to sexual violence. There was low knowledge about HIV—
more than 60 percent either thought incorrectly that HIV could be
transmitted by a mosquito bite or weren’t sure. Despite free HIV
testing, only half of the young MSM had ever been tested for HIV.14
n In India, a survey among 600 men between the ages of 15 and 24 in
villages in Uttar Pradesh found that 55 of the 300 who reported being
sexually active had engaged in anal or oral intercourse, or both, with
a man. Those having sex with men were significantly more likely to
report inconsistent use of condoms, sex with multiple partners, and
at least one symptom of sexually transmitted infections (STIs). Many
reported they had sex with other men because it was an alternative to
having sex with a woman in a socially restricted environment, even
though they felt it was not right to have sex with a man.15
n A study in northern Thailand of more than 2,000 men enrolled in
inpatient drug treatment identified 66 who reported having sex with
men, mostly with partners known as katoey (transgendered male to
female). About one-fifth of the 66 men were under the age of 21. The
66 MSM were more likely than other men to have ever injected or sold
drugs, been in prison, injected in prison, and to be HIV-infected.16


n A study in Thailand also shows that MSM are vulnerable to the
impact of using amphetamine-type stimulants. Use during last sex
increased from less than one percent in 2003 to 5.5 percent in 2007,
and overall the use of these stimulants among MSM increased from
about four percent in 2003 to 21 percent in 2007.17 While this study
did not focus on young people, other studies have found that
methamphetamines are widely used by young people in Thailand.18
n With regard to access to HIV testing, data from 2007 national
surveillance systems in Thailand,19 Cambodia,20 and Indonesia21
showed that about the same proportion of MSM 24 or younger
reported voluntary HIV testing in the past year, compared to
MSM 25 or older: 52 percent compared to 48 percent in Thailand,
35 percent compared to 34 percent in Indonesia, and 60 percent
compared to 64 percent in Cambodia. These reports come from
MSM gathering in “hotspots” rather than all MSM. The earlier a
person is tested, the earlier he can learn his status and get treatment.

These studies provide insights into the types of issues that concern young MSM
in particular. They indicate that many MSM begin same-sex sexual activity at a
young age, and sometimes this occurs with older partners. Among young MSM,
some groups are particularly marginalized, including ethnic minorities, migrants
to cities, those living on the street, HIV-infected young people, and those injecting
drugs. Greater isolation usually means that those who are HIV-infected are likely to
learn about their HIV status later in the course of infection. These studies highlight
the fact that young men have sex with other men for a variety of reasons, ranging
from desire for economic survival in some settings to strict social norms and
gender roles that limit sexually active young men from having sex with women.
Recognizing both the similarities and the differences of such behaviors is crucial
for developing effective prevention programs.


Programmatic Approaches
This wide range of risk factors emphasizes the need for programs to address both
individual behaviors and the social determinants leading to vulnerability (i.e.,
structural changes). In countries where sex between men is illegal, local MSM
organizations, where they exist, generally operate in difficult circumstances with
relatively low levels of funding. They face official resistance, legal impediments,
and high levels of stigma and discrimination. In addition, if such organizations
work with young MSM, they could be seen incorrectly as interested in recruiting
young men into the gay lifestyle, a misperception that might inhibit MSM organi-
zations from working with young MSM. Concerns about the need for parental
consent might also prevent such organizations from providing services to young
MSM. Community-based groups provide essential access to young MSM, but they
require strong links to the health infrastructure, expanded and sustained funding,
and substantial capacity-building assistance.

Peer education within social networks is one approach that has shown some impact.
A randomized study in Russia and Bulgaria recruited 276 MSM (with a mean age of
22.5) through 52 MSM social networks. The leaders in the 25 networks in the study’s
experimental arm received a nine-session training program on HIV risk-related
knowledge and behaviors. They were then instructed to share that information
through their networks. In these 25 networks, those reporting unprotected
intercourse declined from 72 percent to 48 percent at the
three-month follow-up, and those reporting multiple partners
declined from 32 percent to 13 percent.22
Peer education within
social networks
Another promising peer education project among young
has shown some impact
MSM took place in Togo, following the PSI formative research among young MSM.
described above. The program recruited peer educators
(generally between the ages of 18 and 20), distributed condoms
and lubricants, promoted various information events, and
supported mobile testing units. Peer educators used flip charts that dealt with issues
such as multiple partners, stigma, cross-generational sex, and condom negotiation.
The program has reached 3,000 men, many of whom are younger than 24, through
peer education activities, and another 2,000 through mass educational activities.
Involving peer educators who were motivated because the program focused on
their needs enabled the project to reach young men who would not have gone to
conventional services.


The project is now conducting an evaluation of the results so far and hopes to
expand to a wider MSM audience, including young men who do not self-identify as
gay, and to create a national network of reference centers for health and psychosocial
services. The project is supporting local MSM organizations to pursue legal
recognition and protections and to seek additional resources for more confidential
spaces and STI/HIV-related services. The Togolese President and Minister of Health
have recently made public statements recognizing the importance of including
MSM in HIV prevention strategies.

In Thailand, another peer education approach proved successful. According to 2007
surveillance data,23 MSM outreach projects using peer educators reached 52 percent
of MSM between the ages of 15 and 24 during the past year. A significant proportion
of the peer-outreach educators (mainly volunteers) are young MSM working with
older MSM peer educators or outreach workers. This effort is one of approximately
60 programs with MSM and transgender persons that were supported by FHI in
2009, in 10 countries in the Asia Pacific Region and four countries in Africa, involv-
ing 79 implementing partners, and predominantly with USAID funding.

These projects operate within a framework based on a USAID comprehensive
package for most-at-risk populations.24 The framework includes individual- and
group-level programs, peer outreach, linkages to services (HIV counseling and
testing, STI care, and support and treatment), and targeted multi-media campaigns.
The programs include policy and advocacy, strategic information, capacity building,
community mobilization, and decreasing stigma and discrimination. They are
usually carried out in collaboration with other agencies. Within this framework,
strategic approaches to behavioral change can be used that help address the particular
needs of younger MSM.

One of the multi-media campaigns used new technologies to alert MSM networks in
Bangkok and Chiang Mai to the alarming increase in HIV prevalence among MSM:
from 17 percent in 2003 to 28 percent in 2005. This “Sex Alert” campaign used
multiple targeted channels, including the Internet and text messaging. A midterm
review of this campaign at the fifth month of implementation, using a probability
sampling methodology to reach 300 MSM, showed that the campaign reached 94
percent of MSM between the ages of 16 and 25 and 91 percent of those older than
25.25 A final evaluation of the campaign reached similar findings.26


In an environment of marginalization and violence, programs designed to increase
safe sex among individual MSM face many challenges. Efforts to address policies in
Mexico and Brazil demonstrated the value of structural changes, including support
from Ministries of Health that work with civil society groups supporting the lesbian-
gay-bisexual-transgender (LGBT) community.

In Brazil, simultaneous efforts by multiple actors contributed to the current national
response to prevent discrimination against LGBT people. The LGBT community
has worked for more than a decade with Brazilian legislative leaders and the Ministry
of Health to develop innovative approaches to combating HIV, including work with
the president in a national campaign to combat violence and discrimination against
LGBT people. In 2009, the Brazilian government, in consultation with civil society,
issued the National Plan to Promote Citizenship and Human Rights of LGBT
People with a focus on removing homophobia from family, schools, and religious
institutions. Also, the Special Secretary on Human Rights convened a meeting on
public policy for LGBT adolescents and youth, and a strategic plan within the
Ministry of Education emphasizes sexual diversity as part of the country’s pluralistic
society—a program known as Schools without Homophobia.

In Mexico, the president of the National Center for the Prevention and Control of
HIV/AIDS (CENSIDA) has initiated an anti-homophobia campaign focused on
human rights, which includes proposals to address health disparities. In addition,
CENSIDA linked with the Mexican National Campaign for the Sexual Rights
of Young People to promote comprehensive sexuality education without stigma
against sexual orientation and to strengthen interagency collaboration. The
National Center is also emphasizing the importance of reducing homophobia
within the family and is supporting laws to prevent and eliminate discrimination
based on sexual orientation and to protect the rights of youth that include protec-
tion against discrimination based on sexual orientation. CENSIDA is sponsoring a
rights-based marketing campaign with messages such as, “They have the right to
be respected. Only one thing can stop them…Discrimination.” The tag line at the
bottom of this ad says: “These are your rights, from the National Campaign for
the Sexual Rights of Young People.”

The national campaigns in Mexico and Brazil emphasize the need for leading
political groups to understand the marginalization of LGBT youth; to advocate for
improved policies with local, civil society partners; to respond to institutional
and social homophobia with substantial investments; and to integrate sexual and
gender diversity into sexuality education, including curricula and teacher training.


Conclusions and Next Steps
A number of recent meetings have sought to focus more attention on the needs of
MSM. In 2008, the Foundation for AIDS Research (amfAR) convened a global
consultation on MSM and HIV/AIDS research in Washington, DC. Also in 2008,
the WHO collaborated with UNAIDS and UNDP to hold a global consultation on
MSM and the prevention and treatment of HIV and other sexually transmitted
infections. And the same year, the Kenya National AIDS Control Council and the
Population Council convened a technical consultation in Nairobi to address the
prevention and treatment of HIV among MSM in national HIV programs. One
debate in the Africa meeting was over how much to emphasize a public health or a
human rights approach, with a general recognition that both are not only valid,
but also necessary. As one participant put it, “When you walk over hot coals, you
need both of your shoes.”27

Although the meetings and reports did not focus on young men, many of the discus-
sions and conclusions related to young men. These and other meetings emphasize
common program elements that need to be expanded, including the following:
n Creating safe spaces for young MSM

n Developing close working relationships with ministries of health and
AIDS programs
n Involving MSM in the development and implementation of programs
for which they are the intended beneficiaries
n Training and sensitizing providers on MSM-friendly services

In addition to the efforts for all MSM, young men need more focused attention. Few
school-based curricula in low-resource countries have included special attention
to sexual orientation or transgender issues. A recent document from the United
Nations Educational, Scientific and Cultural Organization (UNESCO), however,
has begun to address such issues. The UNESCO guidelines state the following in
the learning objectives that they recommend for ages 12 to 15: “People do not
choose their sexual orientation or gender identity.” The guidelines advocate “tolerance
and respect for the different ways sexuality is expressed locally and across cultures.”28
A recent declaration on HIV prevention through education from the Ministers of
Health and Education in Latin America and the Caribbean says comprehensive
sexuality education will include “topics related to the diversity of sexual orientation
and identities.”29


As local and international programs begin to pay more attention to MSM and HIV
in Africa and Asia, more focus is needed to meet the particular needs of young
MSM. Below are some of the lessons learned from the few projects that have focused
on these young men and some of the priority areas that require further attention:
n Building resilience among young MSM is needed and can be
supported through MSM organizations. These groups can support a
range of programs that contribute to young people’s development
through life skills, mentoring, and job skills. They can also provide
role models, help build community support systems, and contribute to
broader and more inclusive HIV advocacy efforts within countries.
n Gaining more understanding on the unique needs of young MSM
through research in the following areas:
l Culturally specific sexual and gender identities and expressions
that include sexual experimentation
l Unique prevention, treatment, care, and support needs within
youth-focused programming
l Approaches to developing social support from peers, family, and
community, and support for the parents of young MSM so that
they are in turn able to support their children
l Prevention messages that take into account cognitive and physical
development
l Use of new technologies such as the Internet and cell phones to
reach young MSM
l Overcoming barriers to HIV testing for young MSM, because
young MSM might avoid being tested as this can give rise to a
double stigma (MSM and HIV infected)
n Using social networks and peer educators shows promise. The Russia-
Bulgaria study found that engaging the leaders of social networks for
at-risk, young MSM to communicate theory-based counseling and
advice “can produce significant sexual risk behavior change,” although
it remains to be seen how much these behaviors are maintained
over time.30
n Avoid a sharp dichotomy between homosexual and heterosexual, and
address gender issues more broadly, especially in countries such as
India. A recent Consensus Meeting for Caribbean Countries on Access of
Vulnerable Populations to HIV Health Services offered guidance on this


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“Young people most at risk of HIV” (IATT/YP) 2010

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“Young people most at risk of HIV” (IATT/YP) 2010